Wisconsin



Wisconsin Psychoanalytic Society

2323 North Lake Drive ( Seventh Floor ( Milwaukee, WI 53211

Office: (414) 291-7036(Fax: (414) 291-6394



APPLICATION FOR MEMBERSHIP

Student Associate

Psychotherapy Associate

Academic Associate

Special Associate

Affiliate Membership (candidates)

Active Membership (graduates of APsaA Institutes)

Name____________________________________________ Date__________________

Home Work

Address_______________________________ Address__________________________

City/Zip_______________________________ City/Zip__________________________

Work

Phone_________________________________ Phone____________________________

Birth Place_____________________________ Birth Date ________________________

Marital Status __________________________ Spouse’s Name ____________________

Sex ___________ E-mail Address _______________________________

Hospital Affiliations _______________________________________________________

________________________________________________________________________

Faculty Appointments _____________________________________________________

_______________________________________________________________________

DISCIPLINARY ACTIONS: Have any of the following ever been, or are any currently in the process of being denied, revoked, suspended, reduced, limited, placed on probation, not renewed, or voluntarily relinquished? If yes, please provide full explanation on a separate sheet including resolution of charges.

a) Medical license in any state Yes_____ No_____ NA_____

b) Other professional registration/license Yes_____ No_____ NA_____

c) DEA registration Yes_____ No_____ NA_____

d) Academic appointment Yes_____ No_____ NA_____

e) Membership on any hospital Medical Staff Yes_____ No_____ NA_____

f) Clinical privileges Yes_____ No_____ NA_____

g) Prerogatives/rights on any Medical Staff Yes_____ No_____ NA_____

h) Other institutional affiliation or status thereat Yes_____ No_____ NA_____

i) Professional society membership or fellowship Yes_____ No_____ NA_____

j) Professional office Yes_____ No_____ NA_____

k) Any other type of professional sanction Yes_____ No_____ NA_____

l) Have there ever been any felony criminal

charges brought against you? Yes_____ No_____ NA_____

m) Have you been the defendant in malpractice or other litigation pertaining to your professional

work? Yes_____ No_____ NA_____

n) Have you been sanctioned by any professional organization for violation of ethical standards?

Yes_____ No_____ NA_____

PROFESSIONAL LIABILITY INSURANCE

Present private carrier_____________________________________________________________________________

Have there ever been, or are there currently pending any malpractice claims, suits, settlements, or arbitration proceedings involving your professional practice? If yes, please provide a full explanation on a separate sheet. Yes_____ No_____

Please provide us with a curriculum vitae or complete the following:

EDUCATION

Institution Location Dates (From – To) Degree Received

College/

University -

Post-Grad -

Internship or

Residency -

Other Post-

Grad Study -

List professional experience chronologically (clinically, teaching, administrative, etc.):

Publications (brief)

Two references who will submit letters of recommendation.

1.

2.

________________________________________

Signature of Applicant

Wisconsin Psychoanalytic Society

2323 North Lake Drive ( Seventh Floor ( Milwaukee, WI 53211

Office: (414) 291-7036(Fax: (414) 291-6394



RELEASE OF INFORMATION

By applying for appointment to the Wisconsin Psychoanalytic Society I hereby signify my willingness to appear for interviews in regard to my application. I hereby authorize the Wisconsin Psychoanalytic Society, its staff and representatives, to consult with prior associates and others who may have information bearing on my professional competence, character, ethical qualifications, and ability to work cooperatively with others and consent to the inspection of all documents that be material to an evaluation of my professional qualifications and competence.

I hereby release from all liability all representatives of the Wisconsin Psychoanalytic Society for acts performed and statements made in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and I hereby release from liability any and all individuals and organizations who provide information to the Wisconsin Psychoanalytic Society in good faith and without malice concerning my professional competence, ethical qualifications, character, or other qualifications for appointment to the Wisconsin Psychoanalytic Society, and I hereby consent to the release of such information.

________________________________________ _________________________

Signature Date

The Wisconsin Psychoanalytic Society will treat this application and any information secured in connection therewith in strict confidence, preserving with all reasonable safeguards the privacy of the applicant.

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